Appeals Process for TRICARE Claims is Fair, But Long

The agency that runs the Defense Department’s massive health care system rarely has overturned the decisions of independent rulings on appeals from TRICARE beneficiaries during the last five fiscal years, according to a new report.

There’s no evidence that the head of the Defense Health Agency “summarily overturned hearing officers’ decisions,” stated acting Defense Undersecretary for Personnel and Readiness Jessica Wright in a June 4 letter to the leaders of the congressional Armed Services committees. The letter accompanied a report on the TRICARE appeals process that Congress required in the fiscal 2014 Defense authorization act. Of the 124 cases that made it to the final stage of the appeals process from fiscal 2009 to fiscal 2013, the Defense Health Agency adopted in full the hearing officer’s decision to grant payment to the beneficiary who filed the appeal in 106 cases – or 85 percent of the time.

The director of the Defense health agency disagreed completely or partially with the hearing officer’s decision to grant payment in 18 cases during the five-year span in the report. The head of the agency can either overturn the ruling in full, in part, or remand the decision back to the hearing officer.

Advocacy groups for military personnel and their families had complained to Congress that people perceived the TRICARE appeals process as unfair because the director can overturn a decision by the independent hearing officer at the final level of appeal.

The appeals process for TRICARE claims has three levels: reconsideration by the TRICARE contractor that issued the initial denial of payment; second reconsideration by the Defense Health Agency Appeals and Hearings Division; and a hearing before an independent hearing officer. Appeals are considered final if the outcome is favorable to the beneficiary, or the beneficiary decides not to continue the appeal. Wright said in her letter that the department “had improved the timeliness and beneficiary orientation of TRICARE appeals and simplified the appeals process.” The department also has put in place procedures to improve the performance of managed care support contractors and developed a better system to manage work flow and increase efficiency in case management, Wright wrote.

In fiscal 2013, beneficiaries filed 9,246 initial appeals, down from 14,667 appeals filed in fiscal 2009. The number of appeals dropped significantly after the first level; just 124 cases went to the hearing stage in fiscal 2013. It took the DHA on average nearly one year to decide on appeals filed between fiscal 2009 and fiscal 2013 that went to the hearing stage. The average number of days in fiscal 2013 for a final decision from the agency was 298, down from 342 days in 2012 and 375 days in 2011.

TRICARE appeals range from claims involving medical benefits covered under the program to emerging medical procedures or technologies that are in the developing stage and not yet covered under TRICARE. 

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